Provider Demographics
NPI:1992359400
Name:NICKLE, JOHN LOUIS
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LOUIS
Last Name:NICKLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 HAMPSHIRE PL
Mailing Address - Street 2:
Mailing Address - City:THOMPSONS STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37179-5496
Mailing Address - Country:US
Mailing Address - Phone:615-999-0283
Mailing Address - Fax:
Practice Address - Street 1:1651 HAMPSHIRE PL
Practice Address - Street 2:
Practice Address - City:THOMPSONS STATION
Practice Address - State:TN
Practice Address - Zip Code:37179-5496
Practice Address - Country:US
Practice Address - Phone:615-999-0283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN183517163W00000X
NH08178723367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse